Examiner system must be repaired

Consider this scenario: A baby dies after being placed face-down in her bassinet.

The mother, a woman with a history of drug abuse and criminal arrests, passes out on a nearby couch, apparently intoxicated.

This marks the second of her babies to die unexpectedly. And two other children had been removed from her custody by social services officials.

You would think the second baby’s death would prompt aggressive scrutiny from medical examiners, the officials responsible in North Carolina for helping pinpoint the cause of death when someone dies under mysterious circumstances.

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But that would not be a safe assumption. As the death this May of 4-month-old Isabella Nealy shows, the state remains saddled with a badly flawed system of death investigations.

Gaston County Police suspected the child had been neglected before her death. But the medical examiner, after failing to visit the Bessemer City trailer where Isabella died, ruled that she couldn’t say how the baby died. Prosecutors declined to pursue criminal charges.

Relatives could have told the medical examiner about Samantha Cothern’s history of drug abuse and crime, but the examiner didn’t talk to them before finishing her report. It took a call from a family friend for the examiner to learn of the previous baby’s death and the removal of two other children from Cothern’s custody.

As this case shows, the state’s death investigation burden is simply too heavy and too important to be carried by untrained doctors and nurses handling cases in their off-hours.

Reporters Ames Alexander, Fred Clasen-Kelly and Gavin Off revealed recently that the state’s medical examiners visit death scenes in 9 percent of adult cases, and just 2 percent of infant death cases.

State lawmakers have put an extra $1 million in the state medical examiner’s office budget in response to the Observer’s reporting. A legislative committee is recommending more reforms, including increased training and pay for examiners. One list of needs tops out at $50 million.

Lagging tax revenue projections have some in Raleigh fretting about a budget crunch in 2015. There will surely be those who say reforming the system is too expensive. And in truth, fixing death investigations doesn’t exactly make for compelling campaign ad fodder.

But how can we be satisfied with the haphazard, fall-through-the-cracks treatment we gave Isabella Nealy? Given what we know about child abuse and neglect, don’t we owe a greater duty to infants like her?

Lawmakers took appropriate first steps this year to begin remedying the problem. But it was just a start.